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Shana Dorsey first saw the purplish wound on her father's lower back as he lay in a hospital bed in the suburbs of Chicago a few weeks before his death.
His father, Willie Jackson, winced as the caregivers turned his fragile body exposing the deep cutaneous ulcer, also known as pressure sore or pressure sore.
"It was really the first time I saw how much pain my father was in," Dorsey said.
The staff at the Lakeview Rehabilitation and Nursing Center, she said, never told him the severity of the pressure ulcer, which resulted in sepsis, a serious infection that can quickly become life-threatening if it it's not neatly done. While living in Lakeview and another retirement home, Jackson requested several hospital visits for intravenous antibiotics and other infections, including painful surgeries to remove dead skin around the wound.
Dorsey sues the nursing center for negligence and wrongful death by caring for his father, who died at age 85 in March 2014. Citing the privacy laws, Lakeview Administrator Nichole Lockett declined to comment on the issues. Jackson's care. In a court file, the retirement home denied a wrongdoing.
The case, pending in the County Court of Cook County, is one of thousands of people across the country who claim that debilitated hospital patients have undergone stressful, sometimes painful hospital treatments.
My father was like my best friend. Most people go to their mother's house to talk and tell all their secrets, and for me, it was my father.
Year after year, the country's retirement homes have failed to prevent pressure ulcers and other infections that can lead to sepsis, according to a survey by Kaiser Health News and the Chicago Tribune.
Nobody keeps a close watch on sepsis to see how often these infections are deadly.
However, a federal report found that sepsis-related care was the most common reason for transfers of residents from hospital care homes to hospitals and that these cases resulted in death "far more often" than hospitalizations. for other conditions.
A special analysis done for KHN by Definitive Healthcare, a private health care data firm, also suggests that the cost – human and financial – of such cases is enormous.
Looking at data on nursing home residents who were transferred to hospitals and later died, the office found that 25,000 people each year suffered from sepsis. Their treatment costs Medicare more than $ 2 billion a year, according to Medicare bills from 2012 to 2016 analyzed by Definitive Healthcare.
According to Definitive's analysis in Illinois, about 6,000 residents of inpatient retirement homes had sepsis and one in five had not survived.
"It's a huge public health problem in the United States," said Dr. Steven Simpson, a professor of medicine at the University of Kansas and sepsis expert. "People do not go to a retirement home so they can contract sepsis and die. That's what's happening a lot.
The costs of all these treatments are enormous. Court records show that Willie Jackson's hospital, at the end of his life, cost Medicare more than $ 414,000. Medicare pays Illinois hospitals over $ 100 million annually for the treatment of sepsis nursing home residents, primarily in Chicago area facilities, according to Medicare's claim analysis.
Septicemia is a blood infection that can develop in bedridden patients with pneumonia, urinary tract infections and other conditions, such as pressure ulcers. Conscious of the dangers, patient safety groups view late pressure ulcers as an "ever" event, as they can largely be avoided by returning the immobile persons every two hours and taking other precautions. Federal regulations also require retirement homes to adopt stringent infection control standards to minimize damage.
Yet, according to data from state inspections held by the Centers for Medicare & Medicaid Services, failures that can cause sepsis persist and are prevalent in American retirement homes. A large number of lawsuits allege that pressure ulcers and other common infections have caused serious damage or death. The outcome of these cases is not clear because most are settled and the terms kept confidential.
Cook County, where the private legal community is known to take an aggressive approach to nursing homes, has more of these costumes than any other metropolitan area in the United States, KHN and the Tribune found by examining the judicial data.
State inspectors also cite thousands of homes nationwide for deficiencies that could cause damage. The data maintained by the CMS show that since 2015, 94% of homes operating in Illinois have had at least one referral for conditions that increase the risk of infection. These quotes include pressure sores, catheters, feeding tubes and the home's overall infection control program.
"Few infections turn into large infections and kill people in retirement homes," said William Dean, a Miami lawyer with over two decades of retirement home experience on behalf of patients and of their families.
Regulators and patient advocates say most of the blame is due to lack of staff. Too few nurses or medical aids increases the risks of safety issues, from falls to pressure ulcers and infections that can progress to sepsis or even more serious condition, septic shock, which lowers the pressure blood and organs to stop.
The numbers of nurses and aides in nursing homes in Illinois are among the lowest in the country. According to government data analyzed by KHN, 78% of the Chicago area establishments in the six counties are below the national average.
Matt Hartman, executive director of the Illinois Health Care Association, which represents more than 500 retirement homes, acknowledged that understaffing is a problem that diminishes the quality of nursing care.
According to Hartman, Medicaid payment rates for nursing homes – about $ 151 per day per patient on average – are lower than in most other states. Medicaid accounts for about 70% of the incomes of many households, he said.
Last October, CC Care LLC, a group of Illinois retirement homes specializing in the treatment of mentally ill patients on Medicaid, declared bankruptcy, arguing that the "financial problems of the state were disastrous for all nursing homes ".
In July, the CC Care Creditors' Committee argued that the company could not stay afloat by relying on Illinois Medicaid payments, which it described as "slow, irregular, and well below our maturities". ".
Pat Comstock, Executive Director of the Health Care Council of Illinois, said the retirement homes she represents "are evolving in an increasingly challenging environment in Illinois, but continue to give priority to residents in a safe environment." .
A complaint of celebration
Shana Dorsey remembers her father as a calm but friendly man. He worked as a security guard at a uniformed bank and picked up extra business cars in an empty lot adjacent to his West Side building. He sought out the details, loved teaching his granddaughter the state capitals, and was always ready to help his daughter, who now works for a Chicago real estate management company.
But the age and decline of health have caught up with the Army veteran, who in the early 1980s began to show signs of dementia and move into an assisted apartment.
Dorsey knew that her father needed more specialized care when she found him sitting in his favorite fishing chair in his apartment, unable to get up and stay incontinent.
He needed more intense medical and personal care as his kidney disease deteriorated and he became more and more confused, according to medical records. According to his records, in the last 18 months of his life, he has been in and out of hospitals eight times to treat septic bedsores and other infections.
The Chicago law firm, which represents Dorsey, Levin & Perconti, provided KHN and the Tribune with additional medical records and court documents covering Jackson's care.
Jackson had two pressure ulcers at the end of November 2012, when he was first admitted to the Lakeview Care Center by Jesse Brown's VA Medical Center in Chicago, according to his lawyers. girl.
These wounds healed, but in late September 2013, Jackson raised fever and had an infected wound in his lower back that exposed the bone, causing what Dorsey's lawyers called "a pain important. "
The retirement home transferred Jackson to the Presence St. Joseph Hospital in Chicago, where surgeons cut dead skin and administered antibiotics. At that time, the wound was as wide as a grapefruit and had "plentiful and purulent drainage, a foul odor and bleeding," say Dorsey's lawyers. The tests confirmed the sepsis and the wound had become so deep that it infected the sacral bone of his back, a condition called osteomyelitis, according to the lawsuit.
In November 2013, Dorsey moved his father to another retirement home. He needed three more visits to the hospital before Dorsey made the difficult decision to place Jackson in palliative care. He died on March 14, 2014, after failing, according to a death certificate.
In her case, 39-year-old Dorsey claims that Lakeview nurses knew Jackson was "at high risk" of pressure ulcers because of his declining health. Still, the house has not taken the necessary steps to prevent injuries, such as turning it over and repositioning it every two hours, depending on the suit. That did not happen about 140 times in August 2013 alone, said Dorsey's lawyers.
"My father was like my best friend. Most people go to their mother's house to talk and tell all their secrets, and for me, it was my father, "said Dorsey during a testimony in November 2015.
While Lakeview refused to discuss Jackson's treatment, he denied any negligence and argued in court documents that his actions would not be responsible for Jackson's death. Lockett, the house administrator, said the facility "strictly follows" all regulations to minimize the effects of skin lesions that can occur naturally with age.
"We are grateful for the daily opportunity to improve the lives of seniors and other chronically ill populations in our community," Lockett said in a statement.
Control of infection
Infection control is among the most common quotes in retirement homes. Since 2015, inspectors have cited 72% of households at the national level for not having or following an infection control program. In Illinois, this figure represents 88% of households.
Illinois falls below national standards for the risk of pressure ulcers or not treating them properly in retirement homes. Inspectors cited 37% of nursing homes in the country for this deficiency, compared with 60% in Illinois, according to CMS records. Only three states were mentioned more frequently.
In November 2016, the inspectors cited Alden Town Manor's rehabilitation and health care center in Cicero, Illinois, for negligence due to his care of an unidentified 83-year-old man with untreated pressure ulcer wounds. The gangrene had settled down when the staff had sent him to the hospital, where the surgeons ended up amputating his right leg above the knee, according to the inspectors' report and quote. Alden Town Manor had no comments.
Dean, Miami 's attorney, said nursing home staff often miss the first signs of infection, which can start with fever and high heart rate, altering the condition. mental state or not eating. When these symptoms occur, nurses must call a doctor and make arrangements to transfer the patient to the hospital, but this procedure often takes too much time, he said.
"They do not become septic tanks in the ambulance that drives to the hospital," Dean said.
There is little agreement on the amount of staff needed in retirement homes. Federal regulations simply require that a registered nurse be on duty eight hours a day, every day. In 2001, a federal government study recommended a daily minimum of 4.1 hours of nursing per resident, which includes registered nurses, licensed practical nurses, and licensed practical nurses, often referred to as aides. However, it has never become an industry standard or federal regulation.
Most states set lower requirements and face resistance from the industry to raise the bar. A California law requiring 3.5 hours per resident as of July 1 draws many criticisms from the sector, for example.
In addition, staffing can fluctuate, especially during weekends. A recent KHN survey revealed that some days, caregivers could take care of twice as many people as normal.
At a minimum, Illinois requires 2.5 hours of direct care per day for residents. Yet, according to KHN, at least one in four people in nursing homes in the Chicago area live in institutions that do not provide as much care.
Nationally, each aid is responsible for an average of 10 residents; in the six-county region of Chicago, the average is 13 residents per aid.
Federal officials linked the lack of staff to bedsores and other injuries, such as falls. If left unattended, even a small ulcer or sore can become septic, and once that happens, a patient's life is in imminent danger.
In October 2014, Milwaukee-based Extendicare denied wrongdoing but paid $ 38 million to settle a lawsuit against the False Claims Act, accusing it of not having enough staff in 33 nursing homes or falls.
In other cases, federal officials have alleged that some nursing homes over-mediate residents – which could lead to injuries such as falling beds or wheelchairs and bedsores – rather than treating them properly.
Small infections become major infections and kill people in retirement homes.
In May 2015, owners of two nursing homes in Watsonville, California, agreed to pay $ 3.8 million to settle a whistleblower lawsuit, alleging that patients continued to use drugs, contributing to infections. and bedsores.
The case alleged that an 86-year-old man who could barely move after receiving an injection of an antipsychotic medication lost appetite and spent most of the day at home. He had a fever of 102 degrees, but the staff did not inform his doctor for three days, according to the trial.
The hospital doctors then diagnosed a sepsis and an infected pressure sore. The house did not admit the misdeeds and had no comments.
Personal injury lawyers and medical experts say that poor infection control often sends nursing home residents to hospitals for emergency treatment – and that stress can hasten death.
Older people often do not have the ability to recover from an infection, said Dr. Karin Molander, an emergency physician in California and a member of the Sepsis Alliance advocacy group.
This odyssey of multiple, stressful trips to the hospital is a common denominator in lawsuits for negligence and wrongful death involving sepsis or decubitus. KHN has identified more than 8,000 lawsuits across the country between January 2010 and March this year, alleging injuries caused by the non-prevention or treatment of bedsores and other serious infections.
Molander said that severe bedsores indicate that "someone is ignored for an extended period of time".
"When you see patients like that, you drop [patient neglect] complaints with adult protection services, "she said.
Some of these cases resulted in jury verdicts of one million dollars. In 2017, a Kentucky jury awarded $ 1.1 million to the family of a woman who was suffering from bedsores and sepsis in a retirement home. Last year, in a second case, a jury awarded $ 1.8 million to a widow who alleged that a nursing home in Utah had failed to return her husband enough to prevent bedsores, which resulted in his death.
Lawyers filed more than 1,400 cases from January 2010 to March this year at the Cook County Circuit Court, which tops all of the country's metropolitan areas in the KHN sample.
Nursing homes complain that garish billboards intended to solicit customers are a must-see item in Chicago, where many lawyers' websites boast of having recently received verdicts from the public. 39 million dollars on cases of bedsores.
"We see an incredible amount of lawsuits out there," said Hartman, of the Illinois Retirement Homes Association. "We have the feeling of having a target on the back."
Trial lawyers say that retirement homes often try to evade their responsibilities by creating complex structures to limit their liability. However, Hartman called these lawsuits "cash cows" for law firms that can accumulate six-figure legal fees as business accumulates. The retirement home sector is supporting civil liability reforms that would compensate those injured but also provide a quicker solution to claims, he added.
"It's something that needs to be corrected in Illinois," Hartman said.
Preventable hospital transfers
In September 2013, the Centers for Medicare & Medicaid Services reported working to reduce preventable transfers from retirement homes to hospitals. CMS previously described these trips as "expensive, disruptive and disorienting for frail seniors and people with disabilities".
The plans followed a critical audit by the 2013 Department of Health and Human Services, which revealed that Medicare had paid about $ 14 billion in 2011 for these transfers. According to the audit, sepsis care costs Medicare more than the three most expensive conditions combined.
The auditors have not checked whether Medicare has since reduced these costs and are not considering doing so, said a spokesman for the Office of the Inspector General of the HHS.
However, the analysis of billing data by Definitive Healthcare, modeled after the HHS audit, shows little change between 2012 and 2016, both in terms of deaths and costs.
Wendy Meltzer, executive director of Illinois Citizens for Better Care, said that hospital visits caused by the treatment of sepsis can be "emotionally devastating" for older patients confused.
"It's not a choice everyone makes. It's horrible for people with dementia, "said Meltzer. "Some never recover. It's a very real phenomenon and it's cruel.
Chris Cioffi, a master's student at the University of Maryland, contributed to this report.
This story was produced jointly by Kaiser Health News and the Chicago Tribune by reporters based in Washington, DC and Chicago. Fred Schulte is KHN's Principal Correspondent and Elizabeth Lucas is a Data Writer. Joe Mahr is a reporter from Tribune.
The coverage of these topics by KHN is supported by the John A. Hartford Foundation, the Gordon and Betty Moore Foundation and the SCAN Foundation.
Kaiser Health News (KHN) is a national health policy information service. It is an independent editorial program of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
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